R4D Malawi

A systematic review of the evidence of the impact of eliminating school user fees in low-income developing countries.

Fri, 18 May 2012 07:53 GMT

Document Type: Systematic Review
Creator: Morgan, C.; Petrosino, A.; Fronius, A.

Production Year: 2012

Citation: Morgan, C.; Petrosino, A.; Fronius, A. A systematic review of the evidence of the impact of eliminating school user fees in low-income developing countries. EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK (2012) 116 pp. ISBN 978-1-907345-30-2

Summary:

A systematic review of studies of interventions in low-income developing countries that evaluated the elimination of school user fees paid by households – including the five fee categories identified by the World Bank (tuition, uniforms, textbooks, PTA contributions, other materials/activities) was conducted.

Through extensive literature searches and contact with experts in the field, five rigorous experimental and quasi-experimental evaluations were identified, as well as 31 quantitative and qualitative studies that did not meet the criteria for inclusion in effect size estimates but which were examined to map the extent, types and quality of the evidence base in the topic area and to shed light on possible theory, implementation and context issues. Given the small number of studies that met the inclusion criteria and the variation amongst the studies, the results are provided in a narrative fashion, rather than through meta-analysis. Each of the five included interventions took place in sub-Saharan Africa. Three evaluations took place in Kenya, one in Uganda and one in Malawi.

The findings of this systematic review highlight the need for more rigorous empirical research to investigate the effects of various types of school fees elimination policies in low-income developing nations – particularly on the effectiveness of targeting policies to the most vulnerable groups – accompanying trade offs in education quality, and the extent to which fees abolition policies can be sustained over time without undue donor dependency. Research in this area is complicated by the fact that many countries have already implemented universal free school tuition policies for all primary children, so an appropriate control group is difficult to identify and include in an evaluation. One possible solution to this challenge may involve utilising an interrupted time series design involving a single group. In addition, because UPE policies often do not eliminate all household contributions to schooling, additional impact evaluations of nongovernmental or government-supported programmes targeting fees elimination for specific groups can shed more light on the true costs of education for households and the degree to which eliminating these costs can improve schooling and other outcomes for the most vulnerable groups. Longitudinal studies are needed to elucidate the longer-term impacts of fees elimination, including whether initial surges in enrolment are sustained over time and what the policies mean for future educational attainment, employment and other outcomes.

Research to determine the full household costs of education (including opportunity costs for boys and girls) for different socio-economic groups is key, as well as determining how much of the full cost of education households are willing and able to bear, given an acceptable level of education quality. Experimentation with different innovations, such as user fees on a sliding scale based on household ability to pay would be informative and could be researched empirically. Studies such as these can provide valuable information to countries that are considering abolishing school fees and can inform strategies for advance planning and targeting of reforms, including planning for efficient allocation of resources at the local level.

Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia

Wed, 16 May 2012 07:22 GMT

Document Type: Journal Article
Creator: Brugha, R.; Kadzndira, J.; Simbaya, J.; Dicker, P.; Mwapasa, V.; Walsh, A.

Production Year: 2010

Citation: Brugha, R.; Kadzndira, J.; Simbaya, J.; Dicker, P.; Mwapasa, V.; Walsh, A. Health workforce responses to global health initiatives funding: a comparison of Malawi and Zambia. Human Resources for Health (2010) 8 (1) 19. [DOI: 10.1186/1478-4491-8-19]

Summary: Background
Shortages of health workers are obstacles to utilising global health initiative (GHI) funds effectively in Africa. This paper reports and analyses two countries' health workforce responses during a period of large increases in GHI funds.
Methods
Health facility record reviews were conducted in 52 facilities in Malawi and 39 facilities in Zambia in 2006/07 and 2008; quarterly totals from the last quarter of 2005 to the first quarter of 2008 inclusive in Malawi; and annual totals for 2004 to 2007 inclusive in Zambia. Topic-guided interviews were conducted with facility and district managers in both countries, and with health workers in Malawi.
Results
Facility data confirm significant scale-up in HIV/AIDS service delivery in both countries. In Malawi, this was supported by a large increase in lower trained cadres and only a modest increase in clinical staff numbers. Routine outpatient workload fell in urban facilities, in rural health centres and in facilities not providing antiretroviral treatment (ART), while it increased at district hospitals and in facilities providing ART. In Zambia, total staff and clinical staff numbers stagnated between 2004 and 2007. In rural areas, outpatient workload, which was higher than at urban facilities, increased further. Key informants described the effects of increased workloads in both countries and attributed staff migration from public health facilities to non-government facilities in Zambia to PEPFAR.
Conclusions
Malawi, which received large levels of GHI funding from only the Global Fund, managed to increase facility staff across all levels of the health system: urban, district and rural health facilities, supported by task-shifting to lower trained staff. The more complex GHI arena in Zambia, where both Global Fund and PEPFAR provided large levels of support, may have undermined a coordinated national workforce response to addressing health worker shortages, leading to a less effective response in rural areas.

Preparation of a Road Design Manual and Standard Bidding Documents for Low Volume Sealed Roads in Malawi. Workshop Report.

Thu, 03 May 2012 08:35 GMT

Document Type: Meeting Report
Creator: Pinard, M.I.

Production Year: 2012

Citation: Pinard, M.I. Preparation of a Road Design Manual and Standard Bidding Documents for Low Volume Sealed Roads in Malawi. Workshop Report. (2012) 21 pp.

Summary: As part of the AFCAP-supported project on the development of a Road Design Manual for Low Volume Sealed Roads (LVSRs) and related Standard Bidding Documents (SBDs) for Malawi, a Technical Working Group (TWG) workshop was held at the Capital Hotel, Lilongwe on 20th and 21st March 2012. This Workshop Report documents the outcome of the workshop proceedings and subsequent meetings with the RA.

Town Chiefs in Malawi: Some Observations about Informal Mechanisms of Accountability

Tue, 24 Apr 2012 07:50 GMT

Document Type: Book Chapter
Creator: Cammack, D.

Production Year: 2011

Citation: Cammack, D. Town Chiefs in Malawi: Some Observations about Informal Mechanisms of Accountability. In: Chirwa, D.M.; Nijzink, L. (Eds). Accountable Government in Africa: Perspectives from Public Law and Political Studies. Juta Law, South Africa (2011) ISBN 9781919895376

DNA Fingerprint Changes in Tuberculosis: Reinfection, Evolution, or Laboratory Error?

Mon, 23 Apr 2012 07:32 GMT

Document Type: Journal Article
Creator: Glynn, J.R.; Yates, M.D.; Crampin, A.C.; Ngwira, B.M.; Mwaungulu, F.D.; Black, G.F.; Chaguluka, S.D.; Mwafulirwa, D.T.; Floyd, S.; Murphy, C.; Drobniewski, F.A.; Fine, P.E.

Production Year: 2004

Citation: Glynn, J.R.; Yates, M.D.; Crampin, A.C.; Ngwira, B.M.; Mwaungulu, F.D.; Black, G.F.; Chaguluka, S.D.; Mwafulirwa, D.T.; Floyd, S.; Murphy, C.; Drobniewski, F.A.; Fine, P.E. DNA Fingerprint Changes in Tuberculosis: Reinfection, Evolution, or Laboratory Error? Journal of Infectious Diseases (2004) 190 (6) 1158-1166. [DOI: 10.1086/423144]

Summary: Background. DNA fingerprint patterns of Mycobacterium tuberculosis strains vary within individuals and between epidemiologically linked individuals because of pattern evolution, new infections, and laboratory error. We explored the importance of these factors.

Methods. Cultures from individuals in northern Malawi who had been diagnosed with tuberculosis (TB) during 1996–2001 were fingerprinted with restriction fragment-length polymorphism (RFLP). Probable laboratory error was inferred by use of dates or isolated positive cultures. Pattern evolution was explored within and between individuals, and the relative importance of relapse and reinfection was estimated in individuals with recurrent TB.

Results. RFLP results were available for 930 isolates from 806 individuals. The maximum laboratory-error rate was 3.9%. Pattern evolution was more common in linked individuals (17%) than on relapse (11%) or during treatment (3%). Twenty individuals had recurrent TB after completing treatment: in human immunodeficiency virus (HIV)— positive individuals, 7 of 12 recurrences were due to reinfection, compared with 0 of 8 in HIV-negative individuals (P=.01).

Conclusions. The rate of DNA fingerprint-pattern evolution is not linear, and rates of change calculated from repeat cultures within individuals may not be applicable to transmission between individuals. The high proportion of recurrence due to reinfection found in HIV-positive individuals suggests that secondary prophylaxis and/or antiretroviral treatments are needed for such individuals.

Mycobacterium tuberculosis Beijing Genotype, Northern Malawi

Tue, 17 Apr 2012 09:14 GMT

Document Type: Journal Article
Creator: Glynn, J.R.; Crampin, A.C.; Traore, H.; Yates, M.D.; Mwaungulu, F.D.; Ngwira, B.M.; Chaguluka, S.D.; Mwafulirwa, D.T.; Floyd, S.; Murphy, C.; Drobniewski, F.A.; Fine, P.E.

Production Year: 2005

Citation: Glynn, J.R.; Crampin, A.C.; Traore, H.; Yates, M.D.; Mwaungulu, F.D.; Ngwira, B.M.; Chaguluka, S.D.; Mwafulirwa, D.T.; Floyd, S.; Murphy, C.; Drobniewski, F.A.; Fine, P.E. Mycobacterium tuberculosis Beijing Genotype, Northern Malawi. Emerging Infectious Diseases (2005) 11 (1) 150-153.

Summary: In a 7-year population-based study in Malawi, we showed that Beijing genotype tuberculosis (TB) increased as a proportion of TB cases. All the Beijing genotype strains were fully drug sensitive. Contact histories, TB type, and case-fatality rates were similar for Beijing and non-Beijing genotype TB.

Tuberculosis and gender: exploring the patterns in a case control study in Malawi

Tue, 17 Apr 2012 08:06 GMT

Document Type: Journal Article
Creator: Crampin A.C.; Glynn J.R.; Floyd S.; Malema S.S.; Mwinuka V.K.; Ngwira B.M.M.; Mwaungulu F.D.; Warndorff D.K.; Fine P.E.M.

Production Year: 2004

Citation: Crampin A.C.; Glynn J.R.; Floyd S.; Malema S.S.; Mwinuka V.K.; Ngwira B.M.M.; Mwaungulu F.D.; Warndorff D.K.; Fine P.E.M. Tuberculosis and gender: exploring the patterns in a case control study in Malawi. International Journal of Tuberculosis and Lung Disease (2004) 8 (2) 194-203.

Summary: BACKGROUND: In many populations there is an excess of tuberculosis in young women and older men. We explored possible explanations for these patterns, concentrating on human immunodeficiency virus (HIV) status, pregnancy, smoking, cooking smoke exposure, contact with tuberculosis cases within the household or outside, and gender differences in health service usage and diagnostic delay.

DESIGN: Case control study in Karonga District, Malawi.

METHODS: Cases were new tuberculosis patients with bacteriological or histological evidence of tuberculosis. Controls were selected in the community using field-based random sampling.

RESULTS: The study included 598 tuberculosis cases and 992 controls, with an excess of tuberculosis in young females and older males. This was more marked in HIV-positive individuals. HIV infection was a similarly strong risk factor for tuberculosis in both men and women. Tuberculosis was associated with having a family or household contact with tuberculosis for both men and women. For women, but not men, contacts outside the close family and household were also a risk factor for tuberculosis. Tuberculosis was not associated with current or recent pregnancy, or with smoking or smoke exposure. There were no differences between men and women in health service usage or delay.

CONCLUSIONS: In this population, HIV infection and contacts with known tuberculosis patients are important determinants of the gender distribution of cases.

Policy Brief No. 46. Seeds and subsidies: the political economy of input support programmes in Malawi

Thu, 12 Apr 2012 06:58 GMT

Document Type: Briefing
Creator: Chinsinga, B.

Production Year: 2012

Citation: Chinsinga, B. Policy Brief No. 46. Seeds and subsidies: the political economy of input support programmes in Malawi. FAC, Brighton, UK (2012) 7 pp.

Summary: This FAC Policy Brief examines the political economy of input programmes and identifies maize and input subsidies as central to agricultural political debates. Subsidy programmes that are centred on the supply of seed and fertiliser to support maize production to boost national food security have created a strong actor network including key government players, major donor aid agencies and Non Governmental Organisations (NGOs). In recent years, this has created a unique and highly contested political economy of seeds in Malawi. Notwithstanding the strong narratives about national food security or public food aid, the benefits of both national and donor-led subsidy interventions are unevenly distributed, most to the benefit of elites. Moreover, international commercial seed sector players, pushing their patented genetic material, have won out in agricultural policy over local producers and varieties, again to the profit of local elites.

Engendering the bureaucracy? Challenges and opportunities for mainstreaming gender in Ministries of Health under sector-wide approaches.

Tue, 03 Apr 2012 06:15 GMT

Document Type: Journal Article
Creator: Theobald, S.; Tolhurst, R.; Elsey, H.; Standing, H.

Production Year: 2005

Citation: Theobald, S.; Tolhurst, R.; Elsey, H.; Standing, H. Engendering the bureaucracy? Challenges and opportunities for mainstreaming gender in Ministries of Health under sector-wide approaches. Health Policy and Planning (2005) 20 (3) 141-149. [DOI: 10.1093/heapol/czi019]

Summary: The increasing ascendancy of ‘gender mainstreaming’ as the central approach to improving gender equity has largely determined strategies to integrate a gender focus in sector-wide approaches (SWAps). This paper explores the impetus for and process of gender mainstreaming in SWAps in the Ministries of Health in Uganda, Ghana, Malawi and Mozambique, and outlines some achievements and challenges. The shifting and contested relationships between the Ministry of Health, donors and other government ministries (such as Ministries of Finance and Ministries of Women's Affairs/Gender) are important in shaping the opportunities and constraints faced in gender mainstreaming. The refocusing of resource allocation to different sectors has led to changes in the balance of power between the various actors at the national level, with diverse implications for promoting gender equity in health. Some of the achievements to date and ongoing challenges are explored through concrete examples from different countries. These include: the development of structures for mainstreaming, including the dilemmas of the ‘focal points’ approach and the role of national gender mainstreaming machinery; the need for training and building capacity to identify and address gender issues, which involves engaging with new languages and concepts, and developing new skills; building alliances, consensus and momentum; integrating gender concerns into policy and planning documents; and promoting gender equity in human resources in the health sector. Cross-cutting themes underlying these challenges are the need for gender-specific information and ways to finance mainstreaming strategies. Implications are drawn for ways forward, without losing sight of the challenge of translating discourses of gender mainstreaming, and its central ideal of social transformation, into pragmatic strategies in the bureaucratic environment.

Timing and Reconstruction of the Most Recent Common Ancestor of the Subtype C Clade of Human Immunodeficiency Virus Type 1

Tue, 27 Mar 2012 03:45 GMT

Document Type: Journal Article
Creator: Travers, S.A.A.; Clewley, J.P.; Glynn, J.R.; Fine, P.E.M.; Crampin, A.C.; Sibande, F.; Mulawa, D.; McInerney, J.O.; McCormack, G.P.

Production Year: 2004

Citation: Travers, S.A.A.; Clewley, J.P.; Glynn, J.R.; Fine, P.E.M.; Crampin, A.C.; Sibande, F.; Mulawa, D.; McInerney, J.O.; McCormack, G.P. Timing and Reconstruction of the Most Recent Common Ancestor of the Subtype C Clade of Human Immunodeficiency Virus Type 1. Journal of Virology (2004) 78 (19) 10501-10506. [DOI: 10.1128/JVI.78.19.10501-10506.2004]

Summary: Human immunodeficiency virus type 1 (HIV-1) subtype C is responsible for more than 55% of HIV-1 infections worldwide. When this subtype first emerged is unknown. We have analyzed all available gag (p17 and p24) and env (C2-V3) subtype C sequences with known sampling dates, which ranged from 1983 to 2000. The majority of these sequences come from the Karonga District in Malawi and include some of the earliest known subtype C sequences. Linear regression analyses of sequence divergence estimates (with four different approaches) were plotted against sample year to estimate the year in which there was zero divergence from the reconstructed ancestral sequence. Here we suggest that the most recent common ancestor of subtype C appeared in the mid- to late 1960s. Sensitivity analyses, by which possible biases due to oversampling from one district were explored, gave very similar estimates.